Please complete the following questons (where relevant) for the condition you are seeking advice for. Should you wish to have your eye analised using iridology, please upload the images. You can also upload other images, such as skin rashes, etc or documents. (You can complete this form in English or Afrikaans)
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| ID/Passport Number
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| Email address
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| Name and Surname
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| Age
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| Gender
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| If female - Pregnant/Breastfeeding/Using contraception/Hormonal treatment? Describe.
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| Describe the problem that you are seeking help for in as much detail as possible
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| When were you first diagnosed with this condition / when did you first start experiencing this problem
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| How often do you experience this (whole day, when is it worse, every day/week, etc)
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| Name any treatment and dosage that you are currently using for this conditon
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| What makes it worse/better
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| Did you seek any medical advice for this specific condition? When? What was the diagnosis and treatment?
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| Any additional Information (allergies, other conditions, supplements or natural products that you use, anything you would like to mention, etc)
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| Did you read the disclaimer and do you agree with the terms and conditions for using this service and this website
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| Left Eye (optional - upload image for Iridology)
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| Right eye (optional - upload image for Iridology)
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| Upload optional image (eg of skin rash, etc)
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| Optional - upload any scanned documents (eg blood results, medical reports, etc)
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Image Verification
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EMF Contact Form
EMF Contact Form